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psnet.ahrq.gov/issue/systems-approach-address-impact-second-victim-phenomenon
December 07, 2022 - Commentary
A systems approach to address the impact of second victim phenomenon.
Citation Text:
Gamble B, Gamble KJ. A systems approach to address the impact of second victim phenomenon. Health Serv Manage Res. 2022;35(2):110-113. doi:10.1177/0951484820971455.
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psnet.ahrq.gov/issue/organizational-culture-source-high-reliability
December 03, 2018 - Commentary
Classic
Organizational culture as a source of high reliability.
Citation Text:
Weick KE. Organizational Culture as a Source of High Reliability. Calif Manage Rev. 2012;29(2):112-127. doi:10.2307/41165243.
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DOI Google…
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psnet.ahrq.gov/issue/reduction-warfarin-adverse-events-requiring-patient-hospitalization-after-implementation
October 23, 2024 - Study
Reduction in warfarin adverse events requiring patient hospitalization after implementation of a pharmacist-managed anticoagulation service.
Citation Text:
Locke C, Ravnan SL, Patel R, et al. Reduction in warfarin adverse events requiring patient hospitalization after implementat…
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psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations
January 30, 2019 - Commentary
Classic
Risk mitigation in large scale systems: lessons from high reliability organizations.
Citation Text:
Risk mitigation in large scale systems: lessons from high reliability organizations. Grabowski M, Roberts K. Calif Manag Rev. 1997;39(4):152-16…
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psnet.ahrq.gov/issue/organisational-learning-hospitals-concept-analysis
August 21, 2019 - Review
Organisational learning in hospitals: a concept analysis.
Citation Text:
Lyman B, Hammond EL, Cox JR. Organisational learning in hospitals: A concept analysis. J Nurs Manag. 2019;27(3):633-646. doi:10.1111/jonm.12722.
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digital.ahrq.gov/ahrq-funded-projects/improving-management-test-results-return-after-hospital-discharge/annual-summary/2010
January 01, 2010 - Improving Management of Test Results that Return After Hospital Discharge - 2010
Project Name
Improving Management of Test Results that Return After Hospital Discharge
Principal Investigator
Were, Martin
Organization
Indiana University
Funding Mechanism
PAR: HS09-08…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/brownbridge-g-et-al
January 01, 2023 - Brownbridge G et al. 1986 "An interactive computerized protocol for the management of hypertension: effects on the general-practitioner's clinical behavior."
Reference
Brownbridge G, Evans A, Fitter M, et al. An interactive computerized protocol for the management of hypertension: effects on the gener…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/fitzmaurice-da-et-al
January 01, 2023 - Fitzmaurice DA et al. 1996 "Evaluation of computerized decision support for oral anticoagulation management based in primary care."
Reference
Fitzmaurice DA, Hobbs FDR, Murray ET, et al. Evaluation of computerized decision support for oral anticoagulation management based in primary care. Br J Gen Pra…
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www.ahrq.gov/hai/cauti-tools/archived-webinars/breaking-down-barriers-transcript.html
December 01, 2017 - Also with us today is Stacy Martin, the Manager of Infection Prevention and Control Program at Moffitt
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/breaking-down-barriers-transcript.docx
May 12, 2015 - Also with us today is Stacy Martin, the manager of infection prevention and control program at Moffitt
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
Citation Text:
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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digital.ahrq.gov/sites/default/files/docs/page/A_ReferenceLibrary_1.pdf
February 16, 2006 - A_ReferenceLibrary
Appendix A:
Reference Library
APPENDIX A: REFERENCE LIBRARY
PURPOSE: This reference library is intended to provide a focused subset of key papers,
presentations, and other resources to aid readers in understanding the critical issues
underlying the purpose of the Privacy and Securit…
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digital.ahrq.gov/sites/default/files/docs/page/A_ReferenceLibrary_0.pdf
February 16, 2006 - A_ReferenceLibrary
Appendix A:
Reference Library
APPENDIX A: REFERENCE LIBRARY
PURPOSE: This reference library is intended to provide a focused subset of key papers,
presentations, and other resources to aid r…
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - SPOTLIGHT CASE
A Loss of Trust and a Missed Diagnosis
Citation Text:
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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cds.ahrq.gov/sites/default/files/cds/artifact/171/NIOSH_Occupational%20Factors%20Impacting%20Diabetes_Decision%20Log_condensed.pdf
February 01, 2018 - NIOSH Occupational Factors Impacting Diabetes Decision Log, Condensed
February 2018
Guideline Excerpt
…Clinicians should ask about relevant features of current job(s) that are recognized to impact
diabetes management: shift work, ability to take breaks, exposure to heat or temperature extremes,
ability to ea…
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digital.ahrq.gov/2019-year-review/research-summary/patient-engagement-improves-care-and-shared-decision-making
January 01, 2019 - Patient Engagement Improves Care and Shared Decision Making
Research shows that patient engagement in healthcare can lead to measurable improvements in safety and quality. To advance stronger engagement, AHRQ funds research to help patients, families, and health professionals to work tog…
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digital.ahrq.gov/ahrq-funded-projects/comprehensive-information-technology-it-solution-quality-and-patient-safety
January 01, 2023 - Comprehensive Information Technology (IT) Solution for Quality and Patient Safety
Project Final Report ( PDF , 330.88 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily …
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapc.html
December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Appendix C. Case Study and Program Examples
Previous Page Next Page
Table of Contents
The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Chapter 1. Introduction and Program Over…
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digital.ahrq.gov/ahrq-funded-projects/vizhome-context-based-health-information-needs-assessment-strategy
January 01, 2023 - vizHOME: A Context-Based Health Information Needs Assessment Strategy
Project Final Report ( PDF , 725.32 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent th…
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psnet.ahrq.gov/node/845473/psn-pdf
March 15, 2023 - Remote Patient Monitoring
March 15, 2023
Hood C, Sikka N, Van CM, et al. Remote Patient Monitoring. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/remote-patient-monitoring
Remote Patient Monitoring
The delivery of healthcare through electronic communication, or telehealth, has changed greatly since it…